OBJECTIVE: To investigate the socioeconomic and sexual profile of prisoners.METHODS: A study using a quantitative approach, transversal and descriptive, involving 155 prisoners. Data collection was performed from January to March, 2010, in the female penitentiary in the State of Ceará (Brazil), and included data on socioeconomic and sexual characteristics.RESULTS: Most of the young Brazilian women were single with low educational levels and family income, imprisoned for drug trafficking. There was early first sexual intercourse, with stability and little variety of sexual partners. Being a prisoner, using drugs and possessing tattoos/piercings represented common aspects of the participants and their partners. The homo/bisexuality, and prostitution were strongly present. STDs before or after the arrest showed little expression. The guarantee of achievement of conjugal visits and the obtaining of preventive screening still faces major obstacles.CONCLUSION: Despite the vulnerabilities encountered, it was concluded that strategies to promote sexual health in the prison environment should encompass the complexity of the peculiarities experienced by prisoners.

Violence as a social construction leads to increased crime rates in both small and large urban centers worldwide. This increase in crime represents a serious public health concern because its consequences extend to all individuals independent of their ethnicity, socioeconomic class, or religion.

Crime is historically associated with the male gender, and indeed, most Brazilian prison inmates are male. Women account for only 5.31% of the imprisoned population(1), but they are more likely to suffer under prison conditions and are more susceptible to physical and psychological ailments(2,3).

The epidemiological representation of the female felon is a young woman with low socioeconomic and educational status who is unemployed or a prostitute, single or separated, lives in an urban center but has limited access to healthcare services, and who was likely arrested for drug dealing(2,4-6). This profile, together with increases in sexual freedom, has resulted in an increase in new cases of disease within this population(7).

Nonetheless, few studies in the literature have ex amined female prisoners' sexual profile, their health problems, and the prevention strategies used in Brazilian prisons, particularly in regard to sexually transmitted diseases or infection with the human immunodeficiency virus (STD/HIV)(8).

It is worth emphasizing that prisons represent a high-risk environment because the heterogeneity of the incarcerated population results in high exposure to physical and psychological risks and to infectious diseases(9). In addition, the biological characteristics of women make them particularly susceptible to STD/ HIV compared with the male prison population(3).

These factors represent an even greater challenge to health promotion attempts for the incarcerated population. Prevention and promotion measures must be prioritized to decrease the risk factors that increase this population's inequity and vulnerability(10).

Indeed, more attention must be paid to the health promotion among female inmates, both because of the risks inherent to the prison environment and because of the lack of preventive action throughout the prison healthcare system. Nurses' responsibility to extend their aid to vulnerable and stigmatized populations and their role as active agents in the consolidation of the National Program of Healthcare in the Correctional System (Plano Nacional de Saúde do Sistema Penitenciário - PNSSP)(11) prompted an interest in investigating the socioeconomic and sexual profile of female inmates, which is the aim of the present study. The investigation and assessment of female inmates' sexual profile might supply data for the development of future policies and educational strategies to create a differential approach to STD/HIV and sexual issues in general that is specific to the target population.

Because they are confined, prisoners are easily accessible and thus may represent a segment of great interest to those health care providers, particularly nurses, who direct preventive programmatic actions based on the distinct characteristics of the imprisoned population.

METHODS

This report describes a quantitative, descriptive, and cross-sectional study conducted at the State of Ceará correctional facility for women. The institution is located in Aquiraz County-CE. It can house 300 inmates, and because it is currently being restructured to comply with PNSSP stipulations, its healthcare team and physical facilities are appropriate.

The study population included all of the women incarcerated at this institution during the data collection period. Inmates with cognitive impairment that might make data collection difficult were excluded. The calculus for finite populations based on a population size of 258 inmates with a 95% confidence interval, maximum permitted error of 0.05, and 50% prevalence resulted in a sample of 155 women.

Data collection was performed between January and March 2010. Individual interviews were conducted in the prison school classrooms. The participants were recruited in their cells or workplaces and were escorted to the school by the prison wardens.

The data collection instrument included information on the inmates' sociodemographic profile and sexual history and addressed the following variables: age, citizenship, Brazilian state of origin, schooling level, monthly family income, marital status, reason for imprisonment, onset of sexual activity, current sexual partnership and its characteristics, number of sexual partners in the last six months, sexual behavior, history of prostitution, periodicity of intimate visits, history of STD/HIV before and after imprisonment, type of STD, and occurrence and frequency of routine gynecological examinations.

The data were compiled using Statistical Package for the Social Sciences (SPSS) software Version 17.0 and were tabulated according to their absolute and relative frequencies.

The present study was approved by the Research Ethics Committee of Federal University of Ceará, Protocol Nº 229/09, after previous approval from the directors of the participating correctional institution. All of the participants signed an informed consent form.

RESULTS

The data on the inmates' ages indicated a population of very young women enmeshed in the world of crime. The average age of the inmates was 29.4 years. The most prevalent age range was also the youngest, 18 to 24 years old, which included 61 (39.4%) women.

Regarding citizenship, 10 (6.5%) women came from other countries (Spain, Germany, Cape Verde, and the Netherlands) and were under the custody of the Brazilian government for international drug dealing.

Regarding the Brazilian state of origin, most of the inmates came from Ceará (134, 86.5%), as was expected because of the correctional facility's location. Of these, 94 (70.2%) resided in Fortaleza, the state capital, and 40 (29.9%) were from interior towns. The states of São Paulo and Acre were represented by two (1.4%) women each, and the remainder of the states (Paraíba - PB, Piauí - PI, Maranhão - MA, Amazonas - AM, Mato Grosso do Sul - MS, Minas Gerais - MG and Rio de Janeiro - RJ) by only one (0.7%). Unlike the inmates from the state of Ceará, all of the inmates from other states originated from the state capitals. The educational level data for the female inmates were similar to those for a large fraction of the Brazilian population. More than half of the participants (88, 56.8%) had not finished elementary school (i.e., they had less than nine years of schooling). One hundred fifteen women (74.2%) had no schooling beyond elementary school, varying between illiteracy and completion of the ninth grade. Overall, the inmates had an average of 7.2 years of schooling.

The profile of occupation before imprisonment reflected a female population that mostly worked at unsalaried jobs (37, 23.9%). The remainder of the inmates' former occupations (housekeeper, saleswoman, cleaning lady) were characterized by low salaries and little required professional training, which might be related to the inmates' low education levels. Twenty (12.9%) participants were unemployed at the time of arrest.

The data on the participants' family income reflected an unfavorable socioeconomic situation. More than half of the sample (87, 56.1%) reported monthly incomes below the minimum wage; 19 (12.3%) of the women earned up to BRL 200.00. The monthly income of 124 (80%) inmates varied between BRL 82.00 and 1,530.00.

Regarding the participants' marital status, 73 (47.1%) were single, and 70 (45.2%) reported stable cohabitation in either a marital or a consensual relationship.

An analysis of the reasons for imprisonment showed that 82 (52.9%) of the inmates were imprisoned for drug dealing. Larceny (31, 20%) and theft (26, 16.7%) accounted for the remaining cases.

The sexual history of the 155 participants is described in Table 1 below.

An analysis of the data on the age at first sexual intercourse reflected an early onset of sexual life. One hundred twenty-four participants (80.1%) first had sexual intercourse before age 17 years. It is worth emphasizing that 148 (95.5%) women first had sexual intercourse during adolescence, and 46 (29.7%) first had intercourse before they were 14 years old. Among the latter, two women (1.2%) were sexually assaulted during childhood, at five years of age. The average age at the first sexual intercourse was 14.6 years old, varying between five and 23 years old.

Regarding the number of sexual partners in the previous three months, most of the participants (81, 52.3%) reported having had only one partner; 92 (59.4%) reported having had one to three partners. The small variation in the number of sexual partners is remarkable. When questioned about the nature of the partnerships, 86 (55.5%) women rated them as stable and 21 (13.5%) as unstable, whereas 48 (31%) had no partner. Importantly, although they had partners, not all of the participants reported having had sexual intercourse with them in the previous three months. A total of 60 (38.7%) women with or without partners reported not having had sexual intercourse in the previous three months.

Despite the small variety of partners, their characteristics included factors associated with increased vulnerability for the investigated women. Fifty-four (56.8%) women reported that their partners had tattoos and/or piercings, and 53 (55.8%) women reported that their partners used illegal drugs. Moreover, these risk behaviors were also frequent among the inmates themselves: 96 (61.9%) used illegal drugs, 99 (63.9%) had tattoos, and 37 (23.9%) had piercings.

The data indicated that prostitution was highly prevalent among the participants; 53 (34.2%) women reported having engaged in it. In addition, 14 (9.0%) were aware that their female partners were prostitutes, and five (3.2%) were aware that their male partners were prostitutes.

Homosexual activity with inmates at the same institution was reported by 36 (23.2%) participants, and 21 (23.5%) participants reported sexual activity with male inmates. To allow intimate visits between inmates, the women are escorted to the correctional institution for men every two weeks. Although the heterosexual inmates are given condoms before leaving the institution, the homosexual inmates receive very little orientation about or access to STD prevention measures.

Homosexual activity is common in prison, as the high percentage of homosexual relationships reported in the present study reflects. The total number of women who characterized themselves as homo- or bisexual was 57 (36.8%), whereas the remainder of the participants characterized themselves as heterosexual.

The data pertaining to intimate visits, sexual health, and routine gynecological examinations at the participating institution are described in Table 2.

Among 107 women with sexual partners, only 15 (14.1%) participated in intimate visits. Forty-six (43%) heterosexual women with partners did not participate in intimate visits; the same number and proportion also applied to homosexual inmates with partners without intimate visits.

In the investigated institution, intimate visits take place in a location known as the "Venustério". The Venustério is a room where the couples are allowed to stay for two hours every two weeks specifically for the purpose of intimate visits. Only married inmates and those who can prove a consensual union are entitled to such visits, and they are given more condoms more often than other inmates are.

The data on sexual health showed that 21 (13.5%) women exhibited some manifestation of an STD before imprisonment, and nine (5.8%) were diagnosed with an STD in prison. Syphilis was the most common STD diagnosed; 10 (47.6%) participants had syphilis before they were incarcerated, and two (22.2%) further cases were diagnosed in prison. The second most common STD was human papillomavirus (HPV) infection, which affected four (19%) women before imprisonment and one (4.8%) after imprisonment. Six (28.6%) women reported not knowing the type of STD they had before imprisonment, and six (66.7%) reported not knowing which STD they were diagnosed with in prison.

The participating institution has a fully equipped gynecological service where the inmates are assisted by a gynecologist and a nurse. Within the first few months of incarceration, the inmates undergo a preventive examination, and all data are recorded in the clinical records. Inmates who have already undergone examinations and the time of the examination are noted for future reference. Prescription medications are filled by the gynecological service.

When inmates exhibit symptoms but have not been called for an appointment, they may notify the health caregivers and request an examination. However, during the period of the present study, many of the inmates reported having difficulties with scheduling gynecological visits and other aspects of healthcare assistance.

A total of 65 (42%) women had received routine gynecological examinations at the institution; therefore, most of the inmates had not visited the gynecological facility since their incarceration. Moreover, 21 (13.5%) participants had recently arrived at the institution, which might partially explain the high proportion of women who had not received gynecological services.

The data on the periodicity of routine gynecological examinations provided by the 65 women who had received them indicate a situation that must be improved: 18 (27.8%) women reported having routine examinations every six months, and 14 (21.5%) reported having them once a year, whereas 18 (27.8%) stated that the periodicity of their examinations was inconsistent, and 12 (18.4%) had received only one examination since their imprisonment.

Regarding the time since the last preventive examination, some data were favorable. Among the 65 women had ever been examined, 60 (92.3%) had had their last sample collection one year earlier or less, whereas more than a year had elapsed since the last examination for only three (4.7%) inmates.

DISCUSSION

When the National Correctional Department (Departamento Penitenciário Nacional - DEPEN) compiled the data on the Brazilian incarcerated population in 2008 and 2009, it found an inmate age distribution similar to the that observed in the present study, which thus corroborates the finding that individuals are engaging in crime at increasingly younger ages(1). In December 2009 in the state of Ceará, 24.8% of the female inmates were in the 18- to 24-year-old age range(12).

In addition, the number of foreign women arrested in Brazil for drug dealing has increased in the last two years. In December 2009, 544 noncitizen females were arrested in Brazil(1). A study comparing the profile of male and female inmates in Rio de Janeiro found that the proportion of foreigners was five times higher among women than among men and that in all cases, imprisonment was associated with drug dealing(6).

The educational profile of the sample in the present study agrees with that of the total Brazilian prison population between 2008 and 2009. During that period, more than 17,000 inmates had not finished elementary school(1). This limited education exerts a negative influence on job opportunities and increases poverty and underemployment.

The financial situation of the women in the present study is less favorable compared to those of the 86 inmates included in a study in the state of Goiás. Among those inmates, the most prevalent family income level was up to three minimum wages, which was reported by 58.6% of the sample(13). Engagement in crime often serves as a complementary income source, or even as the only means of achieving better financial conditions within a short time.

The marital status data of the inmates are quite relevant because female crime is related to women's affective involvement. Reports of male participation in the offense are still frequent, whether the females are directly or indirectly responsible for the crime (14).

The distribution of the motives for incarceration found in the present study agrees with the DEPEN (2009) data, which indicate that 22.5% of the female inmates in the state of Ceará were incarcerated for drug dealing, 20% for larceny, and 18.8% for homicide(12). In the present study, the data were limited because only four women (2.6%) were involved. At the national level, 32.6% of females were arrested for drug dealing in 1998; this proportion increased to 59% in 2008 and 2009(1).

Among our study's participants, the age at the first sexual intercourse was remarkably early, especially when compared with the data from a study of the Brazilian population aged 15 to 64 years(15). According to the latter study, only 17% of the sexually active women aged 15 to 64 years began their sexual life before age 15 years old; in the present study, 71 (45.8%) of inmates had their first sexual intercourse within that age range. The average age of first sexual intercourse found in the present study (14.6 years) is younger than the 16.7 years reported in a study of 256 female inmates in Venezuela(16).

An early onset of sexual activity indicates that family planning and sexual and reproductive health promotion strategies must pay special attention to adolescent age group because this period might determine the gynecological and obstetrical future of these young women.

Regarding the number of partners in the previous three months, the results of the present study were positive because multiple partners did not represent a risk. However, consistent condom use and partner characteristics are a cause for concern because these factors might be associated with vulnerabilities.

Tattoos/piercings were common among the investigated women and their partners. These features are usually used to assert oneself in a group; however, tattoos and piercings are frequently performed at home without asepsis(17). In addition, the considerable use of drugs by the inmates and their partners increases their risk of acquiring and transmitting HIV and hepatitis.

In addition to the risks mentioned above, a history of prostitution is so common among imprisoned females that it has become part of the epidemiological representation of the female felon. Many incarcerated women engage in prostitution hoping to improve their financial situation, but they end up becoming involved in illegal activities. Even more common is engaging in prostitution to support drug use(2).

Another point that must be included among the vulnerabilities of female inmates is the common occurrence of homosexuality within the prison setting with or without the use STD/HIV prevention measures. A study of 290 female inmates at a correctional facility in São Paulo showed that homosexual relationships prevailed over heterosexual relationships (3).

The situation depicted here is worsened by female inmates' difficulty with ensuring their right to intimate visits in prison(2). Intimate visits with same-sex partners are not guaranteed by the correctional system, which promotes unregulated and unprotected homosexual relations(18).

Intimate visits between male and female individuals in correctional institutions are guaranteed by Resolution Nº 01 (March 30, 1999); however, the women encounter more barriers to claiming this right than men do(19).

In the present study, STDs occurred less frequently compared with the results of a study on the STD prevalence among 125 female inmates in the state of Rio de Janeiro. In the latter study, 31.9% of the participants had a history of STD before imprisonment. Syphilis (11.7%) was the most common STD, which agreed with our findings. The percentage of STD cases after imprisonment was 78.8%, and once again, syphilis was the most common STD(6).

A lack of information about the types of STD, asymptomatic forms, and difficulty accessing healthcare services before and after imprisonment contributes to the misidentification and underestimation of such diseases in a portion of the inmate population investigated in the present study.

The PNSSP addresses the diagnosis, counseling, and treatment of STD/HIV/AIDS; the distribution of condoms among inmates and staff; the elaboration of educational and instructive materials; the need to supply specific medications against HIV and other STDs; and actions aimed at diagnosing and treating STDs according to the syndromic approach strategy(11). However, such actions are encountering institutional difficulties and obstacles that hinder their practical application.

The findings of the present study identify the need to broaden the scope of preventive gynecological examinations at the investigated institution.

Routine gynecological examination in correctional institutions has an importance beyond preventive examination. Given the vulnerability inherent to the female incarcerated population, consultations can provide an important opportunity for counseling, education, and condom distribution in addition to identifying ailments.

CONCLUSION

The sociodemographic profile of the investigated female inmates indicates a population composed mostly of young, single Brazilian women with a low education level and a low monthly family income, most of who were arrested for drug dealing. Before imprisonment, these women worked at jobs that required few or no professional qualifications. This profile also corresponds to that of many Brazilian youths who live under conditions of familial, social and economic destructuration. The fragility of public policies to ensure quality education, housing, leisure, basic sanitation, nutrition, professional qualifications, and job opportunities make it difficult for many people to achieve a satisfactory quality of life and upward social mobility. The vulnerabilities intrinsic to youths whose lifestyles do not forecast a promising future also catalyze crime in Brazil.

As with the sociodemographic profile, the sexual history of the investigated inmates indicated features that must be considered when planning and implementing strategic actions that target this population. Precocity in the onset of sexual intercourse, drug use, presence of tattoos and piercings on the inmates and their partners, homo/bisexuality among inmates, a history of prostitution, a lack of knowledge about STD/HIV, unguaranteed intimate visits, and difficult access to the institutional gynecological service represent major gaps.

Given the results of the present study, strategies for promoting sexual health in the prison setting must consider the complexity of incarcerated women's particular experience. Strengthening individuals' autonomy must be the essence of the educational process, and science, knowledge, and opinions must consider the contexts of female inmates' environmental, social and cultural vulnerabilities.